Healthcare Provider Details

I. General information

NPI: 1215780382
Provider Name (Legal Business Name): RYAN RIVARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2024
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC09 5040
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

203 E BROWNLIE LN
LONG GROVE IA
52756-9755
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6607
  • Fax: 505-272-8045
Mailing address:
  • Phone: 563-209-6740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: